Implementation Science Research for Women Living with HIV in South Africa


HIV persists as a public health emergency in South Africa, especially among women of childbearing age. Additionally, alcohol and other drug (AOD) use and exposure to gender-based violence (GBV) are associated with increased risk of HIV infection and reduced adherence to antiretroviral therapy (ART).[1]  Mounting evidence indicates that large-scale provision of antiretroviral therapy (ART) is key to arresting the HIV epidemic. [2] However, no research has estimated ART adherence rates for women who use substances in South Africa since the government approved the provision of ART to all people living with HIV.

Our Solution

Ensuring access to ART is an important first step in reducing HIV incidence, especially among key populations such as women who use substances and bear the burden of HIV in South Africa. However, implementation in real-world settings presents challenges. This study seeks to assess the feasibility and acceptability of implementing the Women’s Health CoOp (WHC) intervention via a stepped-wedge design [3]  across four standard of care in Cape Town health clinics and four substance abuse rehabilitation centers to reduce HIV risk behavior and increase ART adherence among women who use substances and are living with HIV. [4]


Over the course of four cycles, this study reached 480 women living with HIV who used alcohol or other drugs. We completed field operations in 2018 after completion of final follow-ups and study activities in Cycle 4, which had a 99% follow-up rate. Preliminary data analysis has revealed:

  • Reduction of alcohol use is an important goal in improving HIV care and re-initiation and adherence.

  • ART adherence is less likely in those with severe drinking and AUD without an intervention.

  • Real world challenges in clinic settings with staff shortages, frequent turnover and burn out, and missing laboratory test data—viral load. Conducting booster trainings of the WHC intervention for clinicians increases the likelihood of future sustainability.

Intervention developers should consider the strengths and limitations of their anticipated implementation setting by engaging with key stakeholders before, during, and after the adaptation and implementation process when developing and attempting to scale-up interventions. Future directions of this research include addressing stigma and discrimination at the clinic level, inclusion of PrEP and sexual and reproductive health services, and reaching men and couples.

Funded by NIAAA R01AA022882

PI: Wendee M. Wechsberg, PhD, MS

Wechsberg, W. M., Ndirangu, J. W., Speizer, I. S., Zule, W. A., Gumula, W., Peasant, C., ... & Dunlap, L. (2017). An implementation science protocol of the Women’s Health CoOp in healthcare settings in Cape Town, South Africa: A stepped-wedge design. BMC women's health, 17(1), 85.


Howard, B. N., Van Dorn, R., Myers, B. J., Zule, W. A., Browne, F. A., Carney, T., & Wechsberg, W. M. (2017). Barriers and facilitators to implementing an evidence-based woman-focused intervention in South African health services. BMC health services research, 17(1), 746.

[1] Wechsberg WM, Myers B, Kline TL, Carney T, Browne FA, Novak SP. The relationship of alcohol and other drug use typologies to sex risk behaviors among vulnerable women in Cape Town, South Africa. J AIDS Clin Res. 2012;S1(15).

[2] Tanser F, Barnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science. 2013;339(6122):966–71.

[3] Hemming K, Girling A. A menu-driven facility for power and detectable-difference calculations in stepped-wedge cluster-randomized trials. Stata J. 2014;14(2):363–80.

[4] Mdege ND, Man M-S, Taylor CA, Torgerson DJ. Systematic review of stepped wedge cluster randomized trials shows that design is particularly used to evaluate interventions during routine implementation. J Clin Epidemiol. 2011;64(9):936–48.